Injured professional footballer wins payment dispute
A professional Polish soccer player who was badly injured while training for an Australian club he was under contract to has won a claim dispute with his insurer.
The player, who held a Lloyd’s sports personal accident and illness policy, badly injured his right knee during a training session in September 2019 and underwent surgery. His anterior cruciate ligament (ACL) and medial collateral ligament (MCL) were both ruptured and the surgeon estimated he would not be fit to play football for about a year.
He lodged a claim which was accepted by Lloyd’s, though the insurer ceased benefits on July 23 2020, saying he was no longer totally disabled because he had resumed training.
The player told the Australian Financial Complaints Authority (AFCA) his return to training was for rehabilitation and he had been still ‘totally temporarily disabled’ (TTD) within the meaning of the policy for another five weeks.
AFCA ruled he was entitled to the requested extra payments.
“There is no evidence to show the complainant was able to practice or train at a professional level and in a situation where he was physically available for selection,” AFCA said.
“A person is paid a wage with the expectation that they will play football when required. No club would engage a player who can simply participate in some training activities but is physically unable to play any football.
“The insurer is therefore required to pay the complainant any unpaid benefits from the date it ceased payments to August 31 2020. The medical evidence is consistent in showing he was not medically able to play football before then.”
Shortly after surgery, the player returned to his home town in Poland where he was under the care of a local doctor who provided updates to Lloyd’s on his recovery. In June 2020, the doctor said he had recovered around 85% of his pre-injury capacity and he began training with a local semi-professional football club in a limited capacity.
On July 20 2020, the doctor said he still needed 4-6 weeks before he could train and play with full exertion. He did not play professional football before September 2020.
Lloyd’s said as the complainant was participating in training from June 10 2020, there was no total disablement from that point onwards.
The policy defined total disablement as someone with “complete and total physical inability to participate in their occupation as a result of a bodily injury or illness and is under the regular care of, and acting in accordance with the instructions or professional advice of a health care practitioner.”
“Participate” was defined as “on the active roster of any professional or semi-professional team or is a member of a professional or semi-professional association for which the insured is contractually or otherwise obliged to play, compete or participate, and/or is available and physically able to practice, play, train or participate, and/or engages in any part of their occupation, regardless of whether they do in fact practice, play, train or participate.”
AFCA said that as the complainant’s occupation was professional football player, emphasis should be on the word ‘player’ as that was the occupation he was engaged to do – “to play in professional sports matches, not simply participate in some training activities”.
It said a player training in a limited capacity for the purpose of rehabilitation, doing so with a club he is not contracted or allowed to play for, and in circumstances where he was not physically able to play any football because of injury was not an acceptable interpretation of the policy wording.
“The panel considers the fairest and/or proper construction of the term ‘physically able to practice, … train’ is a player practicing or training at a professional level and in preparation for upcoming matches. This would include the player being available for selection in those upcoming matches,” AFCA said.
See the full ruling here.
